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The inherited patient

with chronic pain on opioids - Case discussion

Andrea Furlan, MD PhDAssociate Professor, Division of Physiatry, University of Toronto

Scientist, Institute for Work & HealthStaff physician and Senior Scientist, Toronto Rehab – UHN

CIHR New Investigator

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Conflict of Interest Disclosures

Opioid Manager App for phyisicans (US$9.99)

My Opioid Manager App and iBook for patients (FREE)

My Opioid Manager print copy ($20)

Both Apps are owned by University Health Network (UHN)

Learning objectives

At the end of this presentation participants will be able to:

1. Remember the questions to use when approached by an inherited patient on opioid

2. Describe the ECHO model

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What should the doctor do?

a) Prescribe the same medications

b) Prescribe the same non-opioids, but refuse to prescribe any opioids on the first visit

c) Prescribe the same non-opioids, reduce the dose of all opioids by half

d) Prescribe the same non-opioids, switch all opioids to morphine once daily and reduce total dose by half

e) Do not prescribe any medication 4

First visit

Mark, 55 year old

Pain diagnosis

• 10 year chronic low-back pain, bilateral knee osteoarthritis

Co-morbidities

• Obesity

• Sleep apnea

Substance use history

• Cigarretes 1 pack/day

• THC 1g/month, recreationally

• No alcohol or ilicit drugs5

First visit

Mark, 55 year old

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First visit

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Mark, 55 year old

Past treatments for pain:

• Physiotherapy, aquatherapy, acupuncture, self-hypnosis

Average Pain Ratings:

• Worst: 10/10

• Best: 8/10 (after hydromorphone)

Function:

• Brief Pain Inventory: 85% pain interference with life

• Lives with 80 year old mother

• Drives. ADLs ok 7

First visit

Mark, 55 year old

Current prescriptions

• Oxycodone CR 40mg q.8.h.

• Hydromorphone IR 4mg as needed, 5 per day

• Transdermal fentanyl patch 50mcg/h q.3.d.

• Diclofenac drops for knees

• Escitalopram 20 mg daily

• Docusate sodium for constipation

• Dimenhydrinate for nausea8

First visit

Mark, 55 year old

Physical exam

• Pain behaviours, depressed mood

• Very limited lumbar ROM

• SLR 30 degrees bilaterally

• DTR symetric bilaterally

• Sensory to LT and PP: hyperesthesia midline L5-S1

• Tender points medial thighs and legs bilaterally

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First visit

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Mark, 55 year old

He has been prescribed by a colleague of yours who used to work in the same team. The colleague moved out of Province. You checked the chart and all medications and doses are correct.

Point of care urine drug screening: as expected

Many signs and symptoms of CS and OIH

Opioid risk tool: 2 (treated depression) 10

First visit

Managing an inherited patient on opioids for chronic pain

1. Is this rational polipharmacy?

2. Can I confirm that drugs and doses are correct?

3. What is your comfort level with that regimen and dose?

4. Is the pain and function better with the opioid?

5. Is this patient at risk if I maintain the same prescription?

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What should the doctor do?

a) Prescribe the same medications

b) Prescribe the same non-opioids, but refuse to prescribe any opioids on the first visit

c) Prescribe the same non-opioids, reduce the dose of all opioids by half

d) Prescribe the same non-opioids, switch all opioids to morphine once daily and reduce total dose by half

e) Do not prescribe any medication

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First visit

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Lucy, 31 years old

Pain diagnosis

• Juvenile rheumatoid arthritis, bilateral hip replacement, R knee replaced, L knee painful, bilateral shoulders painful

Co-morbidities

• none

Substance use history

• none

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First visit

Lucy, 31 years old

Other treatments for pain:

• Daily aquatherapy

• Average Pain Ratings:

• Worst: 9/10

• Best: 4/10 (after hydrotherapy)

Function:

• Brief Pain Inventory: 60% pain interference with life

• Teaches elementary school

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First visit

Lucy, 31 years old

Current prescriptions for pain

• Oxycodone CR 20mg q.12.h.

Over the counter senna for constipation

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First visit

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Lucy, 31 years old

Physical exam

• Mood normal

• Uses a cane

• Reduced ROM R knee

• Sensory to LT and PP: normal

• Tender points medial thighs bilaterally

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First visit

Lucy, 31 years old

She moved to your towm from another Province. She brought the printouts from her pharmacy and the bottle of oxycodone. You confirmed her current dose

Point of care UDS: as expected

ORT: only her age group

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First visit

Managing an inherited patient on opioids for chronic pain

1. Is this rational polipharmacy?

2. Can I confirm that drugs and doses are correct?

3. What is your comfort level with that regimen and dose?

4. Is the pain and function better with the opioid?

5. Is this patient at risk if I maintain the same prescription?

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What should the doctor do?

a) Prescribe the same medications

b) Prescribe the same non-opioids, but refuse to prescribe any opioids on the first visit

c) Prescribe the same non-opioids, reduce the dose of all opioids by half

d) Prescribe the same non-opioids, switch all opioids to morphine once daily and reduce total dose by half

e) Do not prescribe any medication

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First visit

James, 19 years old

Pain diagnosis

• Car accident 2 years ago, partial spinal cord injury T12, neuropathic pain below the level

Co-morbidities

• none

Substance use history

• Smokes marijuana recreationally and medically

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First visit

James, 19 years old

Other treatments for pain:

• Gym 3 days/week

Average Pain Ratings:

• Worst: 8/10

• Best: 4/10 (after pain meds)

Function:

• Brief Pain Inventory: 70% pain interference with life

• Works as a professional photographer (weddings)

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First visit

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James, 19 years old

Current prescriptions for pain

• Morphine once daily 260mg

Docusate sodium

Lactulose

Senna

Gabapentin 600 tid

Baclofen 20 mg bid

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First visit

James, 19 years old

Physical exam

• Mood normal

• Walks independently

• Spasticity in knee extensors

• DTR 4+ with clonus

• Reduced power lower extremities

• Sensory to LT and PP: reduced below T12. Some areas of hyperalgesia

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First visit

James, 19 years old

He moved from another town. You checked PharmaNet and the last prescription was for Morphine once daily 100 mg, 6 months ago.

Urine drug screening: refused to give sample

ORT: used cocaine once when he was 16 years old

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First visit

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Managing an inherited patient on opioids for chronic pain

1. Is this rational polipharmacy?

2. Can I confirm that drugs and doses are correct?

3. What is your comfort level with that regimen and dose?

4. Is the pain and function better with the opioid?

5. Is this patient at risk if I maintain the same prescription?

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What should the doctor do?

a) Prescribe the same medications

b) Prescribe the same non-opioids, but refuse to prescribe any opioids on the first visit

c) Prescribe the same non-opioids, reduce the dose of all opioids by half

d) Prescribe the same non-opioids, switch all opioids to morphine once daily and reduce total dose by half

e) Do not prescribe any medication

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First visit

ECHO (Extension for Community Healthcare

Outcomes) Ontario –Chronic Pain and Opioid Stewardship

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1. Use technology to leverage scarce healthcare resources

2. Share best practices and reduce variation in care

3. Harness practice-based learning and develop specialty training expertise among Primary Care Providers (PCPs)

4. Monitor and evaluate outcomes

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The ECHO Model

What a typical ECHO session looks like…

How does one ‘ECHO’?

• The Hub = Specialists with a personal mission to share their expertise by– De-monopolizing

professional knowledge – Educating in a shame-free

environment– Employing adult learning

principles in a case-based format

– Improving to meet the needs of participants

• The successful Hub is expert at Transformational Leadership

• The Spokes = anyone with a desire to serve the most common needs of a community

• Spokes evolve: – Sit and soak – Present cases – Gain expertise – Some accept referrals &

consultation in their locale– Connect to ECHO less

frequently because Transformational Learning has taken place

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HOW TELEMEDICINE DIFFERS FROM THE ECHO MODEL

Specialist

Primary Care Clinician OR Patient

TELEMEDICINE improves ACCESS

Multidisciplinary Team

FHT

Solo Solo MD

Remote

Outpost

Remote RN

Outpost

FHO

CHC Case Presenter

Inter- Spoke Site Learning

ECHO improves ACCESS + CAPACITY

Using Technology to Bridge Distance

WHAT IS PROJECT ECHO®?Extension for Community Healthcare Outcomes

� ECHO connects local clinicians with specialist teams at academic medical centers in weekly virtual

telemedicine clinics.� Project ECHO shares

knowledge, expands treatment capacity.

� ECHO rapidly disseminates best practices for complex chronic disease management.

The result: Better care for

more people.

Cases from ECHO

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Thank you all for listening!

For more information/to register on ECHO Ontario:info@echoontario.cawww.echoontario.ca

Or contact Rhonda Mostyn, Project Managerrhonda.mostyn@uhn.ca

Or find us on Twitter @EchoOntario!!